With 15,000 new AIDS cases breaking out each day, prevention has now failed for more than forty million people with the disease. Some sixteen million orphans created by this devastating pandemic now depend on family, friends, and government institutions for survival. By the time the Global Fund for HIV/AIDS, Malaria, and Tuberculosis sees any results from the programs it has funded, there could well be another ten million people living with AIDS, and four million more orphans.
Deaths from AIDS are estimated at twenty-two million worldwide. These are big numbers by comparison with any prior human tragedy. In fourteenth-century Europe, the Black Death (bubonic plague) killed twenty-five million. The modern-day death rate from AIDS also ranks with the twenty million murdered in Nazi Germany, although it is not yet as high as the number of those murdered through willful government actions in China (thirty-five million) and the former Soviet Union (sixty-two million) between 1900 and 1987.
As the worlds leader in democracy and global health, the United States has a unique role to play in this crisis. Defining that role, however, first requires that we identify how this disease progressed from an epidemic to a pandemic and imposed tragic death sentences on so many millions of people.
Lack of Medical Standards and Accountability
Since 1986, more than $3 billion has been spent on AIDS by the World Bank and the Agency for International Development (AID), two of the largest international health donors. Lacking good medical standards and accountability in their projects, these donor agencies have done little measurement of the outcome of these expenditures. Where evaluations have occurred, they have been primarily process measuressuch as condom sales and numbers of persons testedrather than actual health outcomes, such as the lowering of infection and mortality rates. United Nations secretary general Kofi Annan has called for a 25 percent reduction in HIV infection rates by the year 2005, but unless donors establish solid medical criteria and use them to evaluate their programs, we will continue to have no idea whether they are making any difference at all.
Microsoft billionaires Bill and Melinda Gates understand this endemic problem in the international health community. In one of their largest health projects, the Global Alliance for Vaccines and Immunization (GAVI), the Gateses have set standards and established accountability for recipients. Countries applying for help must go through a detailed process and are then rewarded if they meet inoculation targets. Auditors check records and evaluate results. The $1 billion vaccination fund has rejected almost 20 percent of its country applicants. This serious attempt at accountability is something new and needed in international health programs.
U.S. Treasury secretary Paul ONeill is advocating this type of results-orientation for all World Bank projects. He has good reason to do this. In an exhaustive evaluation of thirty years of its health projects, the World Bank Operations Evaluation Department concluded, Because of weak incentives and undeveloped systems for monitoring and evaluation within both the Bank and borrower governments, there is little evidence regarding the impact of Bank investments on system performance or health outcomes. The Bank therefore has not used its lending portfolio to systematically collect evidence on what works, what does not, and why.
Money for AIDS has typically been dispersed to many countries, with no determination of which countries might yield the best results through a concentrated effort. International aid administrators have neglected to ask whether more money should go to countries with higher infection rates or higher levels of government commitment, nor have they attempted to discover whether the level of assistance per infected person makes a difference in a countrys infection rate. These strategic questions are crucial to a successful campaign against AIDS, but they have not been asked.
Lack of Integrated Prevention and Treatment
Until several years ago, the international health community funded AIDS prevention only through counseling, mass education, and distribution of condoms. The reasons given for not supporting treatment measures were the high price of antiretroviral drugs (ARVs)(so-called drug cocktails)and the complexity of AIDS treatment. In the United States, this lifeline for AIDS patients has allowed them to return to work, raise their kids, pay taxes, reduce hospital costs, and decrease expenditures on drugs needed to treat the infections that accompany AIDS. International aid organizations, however, did not attempt to bring these benefits to poor countries with high infection rates.
In administering fifteen years of overseas AIDS projects, the international health community paid little attention to the costs and benefits of treatment and its importance to prevention. Administrators contend that the poorest countrieswhich spend only 3 percent of their gross domestic product (GDP) on healthcare, compared with 8 to 13 percent in Europe and the United States, less than $13 per person per year, compared with $2,000 per year in the industrialized world couldnt dream of paying for the expensive Western medicines, sophisticated labs, and trained healthcare workers necessary for AIDS treatment. Moreover, they argued, there was no way that these governments and the international donor community could afford to treat all of the thirty million people then infected with AIDS.
Brazil, however, decided to buck the trend, investing in both treatment and prevention early on in the process. In São Paulo, deaths from AIDS dropped by some 50 percent over three years. The program generated countrywide savings of more than $1 billion through reduced hospital costs and doctors fees and fewer drugs needed for treating the opportunistic infections associated with AIDS. Some 100,000 Brazilians are now still alive because of the governments AIDS efforts. The Brazilian government correctly surmised that savings in healthcare costs and lost workplace productivity would outweigh the cost of AIDS drugs.
Dr. Paulo Teixeira, director of the Brazilian AIDS program, took on critics of an emphasis on treatment, who opposed what Brazil was doing: The policy [of ARV treatment of AIDS patients] had been started ten years ago and had been criticized by international institutions and developed countries because too much money was spent in treatment, while prevention should be the priority. During the last three years, it has become clear that the policy has resulted in lower mortality rates, among other things, and that the cost-benefit ratio was positive. He also refuted the other main argument used by Western health officials, that less-developed countries had no structure in place to provide such care to those in very poor areas. Dr. Teixeira reasoned that since the world health community was reaching tuberculosis and malaria victims, it could reach AIDS victims as well.
Unfortunately for other developing countries, no one was listening to what Brazilian officials and many development economists around the world have been saying: (1) that a rural household affected by AIDS would suffer a 50 percent decline in agricultural output, (2) that AIDS can be expected to reduce the already dismal economies of sub-Saharan Africa by 25 percent over the next twenty years, and (3) that the cost of death and sickness benefits for teachers, including hiring and training replacements, would exceed $200 million by 2016, more than an entire year of Swazilands budget for goods and services. In short, treatment makes long-term economic sense.
As numbers of victims rose and the price of AIDS drugs fell, U.S. academics finally spoke out on the treatment issue. First, it made sense that giving people hope that they would live reasonably long lives would help reduce the stigma of AIDS. People would more willingly go in for testing and be more likely to use preventive measures. Second, the sheer number of orphans from AIDS deaths is a staggering responsibility for governments that refuse to support treatment for their parents. From a cost-benefit perspective, treatment must be pursued as an important component of AIDS programs.
Stuart Flavell of the Global Network of People Living with HIV/AIDS put it more bluntly: Theres a myth which I hate, that somehow thirty-four million people will require treatment tomorrow. They wont; only a small subset of this group who knows their HIV status will. Without access to treatment, VCT [voluntary counseling and testing] is a joke and is destined to have very limited effectiveness. Treatment changes the balance, in terms of people seeking to know their status and to get treatment, also in terms of offsetting much higher costs related to treatment of opportunistic infections and hospital stays.
Tragically, treatment could have been started much earlier; particularly in controlled demonstration projects; companies were quite willing to provide either donated or reduced-price drugs early on. Ten tragic years too late, the international health community is now learning that recently initiated demonstration treatment programs in developing countries, including Africa, can work.
Lack of Government Leadership
Most significant in the sad tale of international AIDS support is the lack of leadership within developing countries themselves. World Health Organization director general Gro Brundtland has emphasized that the ultimate responsibility for the performance of a countrys healthcare system lies with [its] government. She went on to observe that many countries are falling short of their performance potential and must avoid the turning of a blind eye to a systems failings.
A few countriessuch as Uganda, Senegal, Thailand, and Brazilhave had positive results from the resources they have committed to combating AIDS. Most developing countries, however, have neglected the disease. In a December 2001 New Yorker piece on AIDS in India, the head of the UN AIDS program for South Asia, Swarup Sarkar, said, We had very few cases for years. It was possible to do something, and all we did was watch. He lamented further, We have told ourselves so many lies.
Reporting on Chinas HIV crisis in the March/April 2002 issue of Foreign Affairs, the authors conclude, Until very recently, denial and institutional inertia characterized the Chinese governments response to HIV/AIDS. Without action now, UNAIDS estimates that a staggering twenty million Chinese could be infected by 2010.
Lack of leadership is why malaria and tuberculosis still rage on in sub-Saharan Africa despite the long-standing availability of inexpensive, generic drugs with which to treat them. Even when AIDS medicines were offered free of charge or at greatly reduced prices, the South African government refused to accept them, just as it refused to accept the fact that the nation was developing an AIDS epidemic. In South Africa, where some 30 percent of all pregnant women are now HIV-positive, in 1998 Glaxo Wellcome lowered the price of AZT, a drug that greatly reduces the chances of an infected mother passing the AIDS virus on to her newborn baby. Another company, Boehringer Ingelheim, offered the drug free of charge for five years. Health activists had to sue the government to force it to accept the drug.
A New York Times editorial spoke out on the tragedy: Though it is hard to imagine a more malignant evil than apartheid, AIDS has already taken more South African lives. If [South African president] Mbeki does not begin to address the crisis, millions more deaths will follow. Only in April 2002 did the South African government agree to a court order to make these medicines available. The number of babies already doomed by this South African policy would, in fact, merit dishonorable mention in the list of twentieth-century megamurders compiled by R. J. Rummel in his book Death by Government (1997).
In general, Third World governmentssupported by many First World international healthcare expertscontend that because they spend less than $13 per person per year on healthcare, they lack the funds to pay for AIDS drugs, even though the price per patient has been reduced to less than $1,000 per year. Where, however, is it written that governments must spend no more than $13 per personor 3 percent of their economyon healthcare? Most African countries spend more of their GNP on military forces than on their peoples physical health. In 1999 the South African government announced a military arms purchase package amounting ultimately to over $7 billion.
The South African Council of Churches (SACC), concerned about such arms sales when there was no military threat, urged Sweden and all European Union member states to review proposed arms transactions for forty-eight fighter aircraft and four submarines. The Reverend Charity Majiza warned, 48 JAS-39 Gripen fighters alone will cost South Africa close to 4 billion Randenough to construct more than forty thousand classrooms. South Africas Minister of Health, Dr. Manto Tshabalala-Msimang, said, We just cannot afford the medicine. If I want to buy antiretrovirals, I would have to forget everything else, even at the reduced costs that are being talked about. She should talk to the Minister of Defense. Foregoing a few fighter aircraft or even one submarine could provide South Africa the means to start treating the 20 percent of its adult population who are infected with AIDS.
Public health expenditures, in any event, are an incomplete measure of what a countrys population can afford. Over 50 percent of all health spending in developing countries is private. Faced with understaffed and under-equipped public health care facilities, poor people have spent their own money and made their own choices in health care for years.
Until the leaders of developing countries fully recognize their AIDS problems, the disease will not be cured and will in fact continue to spread. The only responsible course of action for these countries is to increase spending and create better facilities while cleaning up the corruption in their governments and creating conditions for a healthy private economic sector. They cannot, however, credibly entreat international donors for more AIDS money when they spend fortunes on military ventures while slighting the physical health and indeed the very survival of their own people.
What Should Not Be Done
Massive foreign aid transfers are not the answer. They would be wasteful and ineffective in the absence of measurable results and leadership. Students of development aid need to understand and acknowledge this reality. There has been no demonstrated relationship between foreign aid money and lower AIDS infection and mortality rates, despite billions of dollars spent on AIDS programs by donor agencies. This dismal fact reflects the relationship between foreign aid and poverty reduction. The Oxford Policy Institute found that, on average, the effect of aid on poverty has been neutral, and the World Banks research has shown that countries implement reforms when they choose to, not because of aid funds offered or withheld. In fact, in the last quarter century, the donor community has spent $100 billion on international health programs. This increased financing was the result of a 1977 global health conference that called for Health for All by the Year 2000. The money was supposed to build developing nations primary healthcare infrastructures so that they could deliver health programs more effectively. Yet despite these massive, well-intentioned contributions, in 2002 developing countries claim to be unable to deliver AIDS programs because they lack a suitable healthcare infrastructure.
The old ways remain nonetheless. Jeffrey Sachs, Chair of WHOs Commission on Macroeconomics and Health, claims that billions, not millions, are needed from the United States for global healthcare. Sachs simplistically suggests that the United States can combat AIDS in Africa with the equivalent of $10 a year for every American, the cost of a movie ticket with popcorn. He and others on the Commission on Macroeconomics and Health at the World Health Organization need to explain first, however, where the last $100 billion went. Where is the infrastructure? Whatever happened to Health for All by the Year 2000?
Ultimately, if the donor community will measure the effects of its efforts and learn what works and why, Americans might be wise to contribute more to these organizations. In the meantime, however, to continue the present big-numbers game in foreign aid flies in the face of everything we have learned about the subject.
What Should Be Done
The AIDS pandemic can be solved through a few basic means. One, we need clear standards that measure infection and death rates, not just process indicators as are used now. Second, the effort will require both prevention and treatment programs. And third, the developing countries themselves will have to provide greater leadership and financial commitment.
Foreign aid does have a role in combating AIDS, but it is a very different role from that which it played in the past. Foreign aid should be used to leverage private-sector resources, assisting both for-profit and not-for-profit efforts. Past foreign-aid programs have funded only prevention and education in developing countries, directing their aid through national ministries of public health. These organizations, however, have neither the skills nor the responsibility for treating diseases such as AIDS, malaria, and tuberculosis. International health donors actually do very little to support the curative side of healthcare, such as medical schools, teaching hospitals, and the development of other centers of medical excellence. Although in no developed country is preventive care isolated from curative care, international health aid organizations have consistently promoted this artificial division in developing countries. Treatment and prevention, however, can only be effective if both are securely anchored in the countrys curative care system.
Hence, Americas foreign aid programs should be reaching out to the U.S. public and private curative sector, including medical schools, teaching hospitals, professional medical societies, and the pharmaceutical and medical devices industries to link these U.S. groups to the corresponding curative care institutions in developing countries. In this way, medical professionals in the United States could share knowledge on the latest treatment and prevention protocols with medical professionals in developing countries. Pharmaceutical and medical-device companies should be encouraged to continue their present efforts to provide products through donations and subsidized prices. They can also bring their vast knowledge of clinical outcomes, side effects, and quality control to AIDS treatment and prevention programs. The research and development-based pharmaceutical industry has donated more than two billion dollars of medicine and other funding in the last several years. These companies are partnering with U.S. foundations such as the Bill and Melinda Gates Foundation and Ted Turners UN Foundation. Americas official foreign aid endeavors should help foster these types of partnerships.
Some government and private aid should be devoted to helping link medical professionals in the United States with their medical peers in developing countries to build institutions overseas and create lasting relationships with one of Americas most important assetsits world-class medical facilities and technology. Under such a plan, American medical institutions would provide volunteer doctors, nurses, and technicians, and foreign aid would take care of the more difficult budget items, such as overseas travel and training costs.
This approach is similar to the development model that helped spawn the Green Revolution in agriculture in the 1950s and 60s, which raised farm yields worldwide and helped avert mass starvation when populations rose rapidly in the past few decades. Foreign aid funds enabled leading U.S. centers of agricultural excellence to work with counterpart institutions in developing countries. These efforts enabled Nobel Peace Prize winner Norman Borlaug and other scientists to cooperate in creating high-yielding cereal varieties. This development led to revolutions in production and exports in even the poorest countries. The same model was used successfully in creating partnerships between U.S. and Eastern European hospitals after the crumbling of the Berlin Wall. The International Executive Service Corps also uses this concept, in recruiting retired business volunteers to help people in developing countries assemble successful start-up companies.
It certainly makes more sense to leverage foreign-aid healthcare dollars by employing American healthcare experts than to lavish money on expensive consultants with high overhead rates who are neither trained in nor directly involved in the delivery of AIDS programs in the United States. The partnership concept would enable U.S. medical practitioners to have peer-to-peer relationships with their African counterparts at much lower costs to the U.S. taxpayer. These professionals could then create lasting relationships through which to cooperate on dealing with long-term problems such as the huge burden AIDS and other chronic diseases places on the developing countries economies. This concept leverages much more money from foundations and industry than the U.S. government can by itself provide. The centers of excellence created by these partnerships can be owned and operated by professionals in the developing countries and continually linked to external sources of top-notch medical resources.
There will be no progress in lowering AIDS infection and death rates until the international health community starts measuring results, fully incorporates treatment into its programs, and insists on financial and moral leadership from its aid recipients. International assistance can play a role, but it will have to be radically different from what its purveyors have attempted so far. In particular, U.S. medical expertise and technology from both public and private institutions should be linked with overseas facilities that practice medicine and train medical professionals. International AIDS programs will have to marshall the vast expertise of the entire U.S. private medical sector, including pharmaceutical and medical device companies, if such foreign assistance is to bring any real results.
If we have learned one thing about foreign aid over the past fifty years, it is that pouring additional billions into the same global programs without seriously evaluating past efforts doesn’t cut it. An internal evaluation of World Bank health programs put it best: The overarching recommendation of the review is that the Bank should seek to do betternot morein the HNP [Health, Nutrition, and Population] sector.